Implementing a REBOA Program Outside Large Academic Trauma Centers: Initial Case Series and Lessons Learned at a Busy Community Trauma Program

Abstract

Background: REBOA has become an established adjunct to hemorrhage control. Prospective data sets are being collected, primarily from large, high volume trauma centers. There are limited data, and guidelines, to guide implementation and use outside of highly resourced environments. Smaller centers interested in adopting a REBOA program could benefit from closing this knowledge gap.
 Methods: A clinical series of cases utilizing REBOA from Grand Strand Medical Center, Myrtle Beach, South Carolina were reviewed. This represents early data from a busy community trauma center (ACS Level 2), from January 2017 to May 2018.
 Seven cases are identified and reported on, including outcomes. Considerations and ‘lessons learned’ from this early institutional experience are commented on.
 
 Results: REBOA was performed by trauma and acute care surgeons for hemorrhage and shock (blunt trauma n=3, penetrating trauma n=2, no- trauma n=2). All were placed in Zone 1 (one initially was placed in zone 3 then advanced). Mean (SD) systolic pressure (mmHg) before REBOA was 43 (30); post REBOA pressure was 104 (19). N=4 were placed via an open approach, n=3 percutaneous (n=2 with ultrasound). All with arrest before placement expired (n=3) and all others survived. Complications are described. 
 Conclusions: REBOA can be a feasible adjunct for shock treatment in the community hospital environment, with outcomes comparable to large centers, and can be implemented by acute care and trauma surgeons. A rigorous process improvement program and critical appraisal process are critical in maximizing benefit in these centers.

Strategies for successful implementation of resuscitative endovascular balloon occlusion of the aorta in an urban Level I trauma center

“…Other studies have described the importance of developing a trauma-specific endovascular inventory supply that is organized according to equipment type. 3,24 The cart is supplied with the REBOA kits, sterile gloves and gowns, 18-gauge needles and syringes, saline flushes, contrast, iodine, suture, a sphygmomanometer, scalpels, and gauze. With the development of the REBOA cart, in addition to educational and planning meetings, the ED staff, including the nursing teams, embraced the innovation led by our trauma team.…”

“…8,23 In addition, surgeons performing the REBOA have the required training of vascular anatomy and pathology to become board certified by the American Board of Surgery, therefore possessing the essential knowledge and skills for REBOA placement. 3,6,9 At our institution, the American Board of Surgery certification is a mandatory component to become eligible for REBOA placement either as the proceduralist or as the instructor to a trainee.…”

“…R esuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive tool for the occlusion of the aorta for hemorrhage control and the enhancement of central perfusion to facilitate resuscitation in the setting of hemorrhage. [1][2][3][4][5][6][7][8][9][10] Traditionally, resuscitative occlusion of the aorta involved a thoracotomy, which requires operative closure. Mortality rates remain high for hypotensive patients with truncal abdominal hemorrhage who live long enough to receive a laparotomy-these rates have not changed in the last two decades.…”

“…4,[6][7][8][18][19][20] There are several published articles on the strategic methods of initiating and sustaining a REBOA program in a variety of settings, but little is published on this topic for major metropolitan trauma centers. 3,9,10 The implementation of new technology into an established trauma program requires several key components. Essential are early adopters who garner interest and have the willingness to obtain new skill sets.…”

“…Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive tool for the occlusion of the aorta for hemorrhage control and the enhancement of central perfusion to facilitate resuscitation in the setting of hemorrhage 1–10 . Traditionally, resuscitative occlusion of the aorta involved a thoracotomy, which requires operative closure.…”